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Back to 2014 Annual Meeting Abstracts
Implementation of Best Practices in Colorectal Surgery At a Safety Net Hospital: Facilitators and Barriers
Zeinab Alawadi*1,2, Uma Phatak1,2, Isabel Leal1, Burzeen E. Karanjawala1, Stefanos G. Millas1,2, Julie Holihan1, Tien C. Ko1, Lillian Kao1,2
1University of Texas Health Science Center at Houston, Houston, TX; 2Center for Surgical Trials & Evidence-based Practice, Houston, TX
BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathway is known to reduce complications and length of stay in colorectal surgery patients. However, it is unclear whether an ERAS pathway would be feasible at a safety-net hospital. The aim of this study is to identify local barriers and facilitators to implementation of ERAS pathway for colorectal surgery patients at a safety-net hospital.
METHODS: Semi-structured interviews were conducted to assess current practice, knowledge of the evidence, willingness to adopt the pathway, and perceived barriers and facilitators to change. Stratified purposive sampling was used. Interviews with 8 anesthesiologist, 5 surgeons, 6 nurses and 10 patients were audiotaped, transcribed verbatim and coded using qualitative content analysis. To ensure rigor in data analysis we developed a coding frame to review all transcripts; used participant's quotes; and employed analytic triangulation to establish credibility.
RESULTS: Medical staff addressed factors specific to ERAS implementation, while patients spoke to those related to general recovery. The categories identified across the different medical professions as facilitators were: 1) feasibility, alignment with current practice, 2) smallness of community, 3) good working team and communication, and 4) caring for patients. The barriers were: 1) adapting to change, 2) lack of coordination between different departments, 3) special patient population, 4) limited resources, and 5) rotating residents. Medical staff were familiar with the majority of the ERAS pathway, although practice was not routine. Exceptions included preoperative carbohydrate loading which was perceived to have limited evidence by most surgeons and anesthesiologists, and early mobilization and preoperative education, which were considered important for patient recovery but were not utilized secondary to limited resources. The categories identified in patient interviews as facilitators of overall recovery were: 1) welcoming a speedy recovery, 2) comfort, being well-cared for, and 3) good social support. The barriers were: 1) need for prolonged rest and 2) lack of quiet and private space. Both medical staff and patients expressed an overwhelming positive attitude and support for implementation of ERAS.
CONCLUSION: Use of a qualitative approach accessed what key stakeholders identified as the most important factors on the organizational, practitioner and patient level, impacting improvements in outcomes and efficiency of care. While limited hospital resources is perceived to be a barrier to ERAS implementation at a safety-net hospital, there is strong support for such pathways and multiple factors were identified that may facilitate change. The findings of this qualitative study serve as a basis for modifying and designing interventions targeted to the needs of this population and hospital setting.
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